LEGAL AID SOCIETY OF ORANGE COUNTY, INC. 9 -2002

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'""' ""'" DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMS 0348-0046 'See reverse for public burden disclosure,) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D a. contract Da. bidlofferlapplication D a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only: d.loan year quarter ______ e. loan guarantee date of last report _________ f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 'is a Subawardee, Enter Name o Prime o Subawardee and Address of Prime: Tier ------. If known: Conaressional District, if known: Conaressional District, if known: 6. Federal Department/Agency: 7. Federal Program NamelDescription: CFDA Number, if applicable: ________ 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, M/): differentfrom No. 10a) (last name, first name, M/): (attach Continuation Sheet(s) SF-LLLA, if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ------ D actual D planned o a. retainer o b. one-time fee 12. Form of Payment (check all that apply): o c. commission D a. cash D d. contingent fee D b. in-kind; specify: nature ------ o e. deferred value -------- Of. other; specify: ~_~____ 14. Brief Description of Services Performed orto be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated In Item 11: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheet(s) SF-LLLA attached: DYes DNo 16 Information requesled through this form is authorized by title 31 U.S:C. section Signature: . 1352. This disdosure of lobbying activities is a material reprBSl:ll1tation of fact upon whiCh reliance was placed by the tier above when this transaction was made Print Name: or entered into. This disdosure is required pursuant to 31 U.S.C. 1352. This informatioo will be reported to the Congress semi-annualy and will be avaIlable for Title: pub"c inspectioo. My person who fails 10 file the required disdosure shall be subject to a civil penaltyofnolless that $10,000 and nolmorethan $100.00 o far T alephone No.: Date: each sudl failure. Federal Use Only: I Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)